What’s In a Name? Chikungunya and Dengue Viruses and the Blood Supply

“Incurable Virus Spreads in US!” In recent weeks, breathless and scary-sounding headlines like this have been seen in newspapers and web sites in the United States, describing an outbreak of emerging viruses with scary names like “Chikungunya” and “Dengue” seen in US travelers to the Caribbean, South America, and other tropical areas. While the news certainly sounds terrifying to the public, Transfusion Medicine professionals must evaluate donors carrying these “emerging” infections (defined as infections whose human incidence has increased in the last 20 years or so) as scientifically as possible to ensure the maximum safety of the blood supply. Let’s take a quick look at two of these infections and their implications for potential blood donors.

Chikungunya virus:

Chikungunya has quite possibly the greatest name in the history of viruses! Sadly, it is a fun-sounding name for a not-so-fun disease. This virus has been on our radar for a few years now, as it spread through Africa, Southeast Asia and parts of Europe. More recently, however, Chikungunya has become quite prominent in the Caribbean islands as well as Central and South America.

  • Vector: Aedes species mosquitoes
  • Spread: Human to human via mosquito vector
  • Illness: High fever, severe joint pain that may last months, severe infections in already ill adults or neonates
  • Treatment: No specific therapy or vaccine; just support symptoms
  • Blood transmission: No cases reported, though theoretically possible
  • Tests for donors: None approved by FDA

Though the CDC is monitoring numerous cases of Chikungunya in US citizens in multiple states exposed through mosquito bites during travel, we currently do not have great ways to track or test blood donors. Fortunately, at least 80% of people infected with this virus are symptomatic, and as a result, would be deferred from blood donation simply because they don’t feel well.

Dengue:

Dengue is another emerging infection that has been recently seen in US citizens, primarily those who travel to Asia and South America (in fact, according to the February 2014 update to the AABB Dengue virus fact sheet, Dengue is the most frequent cause of fever in US travelers returning from those areas; source: AABB web site). Worldwide, Dengue is a MASSIVE problem, affecting millions and killing over 22,000 people every year (source: CDC Dengue web site).

  • Vector: Aedes species mosquitoes
  • Spread: Human to human via mosquito vector
  • Illness: High fever, rash, headache, severe lower back pain known as “break-bone fever”; Rare cases with hemorrhagic or shock
  • Treatment: No specific therapy or vaccine; just support symptoms
  • Blood transmission: Multiple well-proven transmissions from RBCs, platelets, and plasma
  • Tests for donors: None approved by FDA

Dengue and Chikungunya infections can present in a very similar manner (high fever and joint pain). Dengue, however, is associated with much more severe consequences in a few patients, with diffuse hemorrhage and complete systemic collapse seen in a few patients.

Together, these viruses infect millions of people around the world every year. However, to date, neither has proven to be a large issue in US blood donors. In addition to the fact that potential blood donors infected by either virus will often be deferred because they do not feel well, many will also be prohibited from donating because they have traveled to an area where malaria is endemic (the malaria travel deferral covers much of the distribution area for both Dengue and Chikungunya).

It is clear to all Transfusion Medicine professionals that we are not completely “safe,” even though we have not yet seen an abundance of transfusion transmission of Dengue, and none whatsoever with Chikungunya. The presence of these non-treatable infections is simply another reminder that transfusion has risks aside from the ones that clinicians and patients think about most (HIV and hepatitis, for example). A big part of the job of a Transfusion Medicine professional is to help our clinician friends ensure that transfusions are only given when absolutely necessary.

 

Chaffin

Joe Chaffin, MD, is the new Vice President and Chief Medical Officer for LifeStream, a Southern California blood center headquartered in San Bernardino, CA. He has a long history of innovative educational efforts and is most widely known as the founder and chief author of “The Blood Bank Guy” website (www.bbguy.org).

 

A Trifecta: It’s About Time!

I am always amazed and interested at how events often occur in 3’s. If you are from Kentucky (or follow the “ponies”) you are likely familiar with the racing 3’s, aka the Triple Crown, of which the Derby is the opening event. There is also the trifecta which is defined as a successful bet for the top three winners in a race: win, place, and show. Well, I believe we have recently (and I might add, finally) achieved a trifecta for Patient Blood Management (PBM).

The trifecta of which I speak is the long-awaited and anticipated national recognition of PBM and thus, transfusion safety.

The first of the three events which initiated my designated trifecta was the American Medical Association and Joint Commission Overuse Summit which took place in 2012. Blood transfusions were recognized and listed within this committee’s top five over-utilized procedures/therapies. A complete discussion of the findings of this summit has been published on the Joint Commission’s website.¹

The second and equally important event was the soon-to-follow Choosing Wisely Campaign, sponsored by the American Board of Internal Medicine (ABIM) Foundation in 2013. Two of the top 5 recommendations pertain to PBM. Restrictive transfusion practices and minimizing overuse of laboratory testing which avoids iatrogenic blood loss anemia were both highlighted.² Several professional societies have embraced the Choosing Wisely Campaign and now have published specific recommendations for their own subspecialties. These include the American Society of Hematologists (ASH), American Association of Blood Banks (AABB), the American Society for Clinical Pathology (ASCP), and the American Society of Anesthesiologists (ASA). The list continues to grow. The American Hospital Association (AHA) has subsequently published a white paper mirroring these recommendations.³

And then the veritable “icing on the cake” has been the recent 2014 release of the AABB Standards for PBM.⁴ These standards place direct focus on the numerous distinct elements of a robust PBM program with levels of activity for all facilities/systems large and small. I imagine many of you have seen the May issue of the AABB News.⁵ This entire publication speaks to the integrated efforts of the ABIM, AHA and other groups that now have joined, in unison, the song of PBM.

Many of us have been beating the PBM drum for several years. Even those of you that are early in your “journey” are embracing it readily in your loco-regional arena. I applaud you! We should be pleased and proud that the drums have finally resonated with leaders of our nationally-recognized societies, accreditation bodies and medical professional groups. This will help to bring PBM and our mission for transfusion safety even more directly into the limelight.

I’m a good old Kentucky girl and I love to score a trifecta. This is a good one and it’s about time!

References:

¹www.jointcommission.org/overuse_summit/

²www.choosingwisely.org

³www.aha.org

⁴www.aabb.org

⁵AABB News, May, 2014; 16: 1-22

 

Burns

-Carolyn D. Burns, MD, is a Board Certified Pathologist who has worked as a medical director for transfusion services and an assistant clinical professor of pathology. She frequently speaks about topics such as transfusion reactions, transfusion in solid organ transplant, and anticoagulant/antiplatelet reversal strategies.

 

Molecular Testing in Transfusion Medicine

Last week, the FDA approved the Immucor PreciseType Human Erythrocyte Antigen (HEA) Molecular BeadChip assay. This method determines non-ABO antigens on red blood cells and is the first molecular assay for determining blood compatibility to be approved by the FDA.

What do you think, blood bankers? When it comes to blood compatibility, do you trust molecular diagnostics as much as serological methods?

ASCP Call for Abstracts

Do you want to present your research at a national meeting? The American Society for Clinical Pathology is currently accepting abstract submissions for their Annual Meeting. This year it’s in October in Tampa, Florida. Soak up the sun while presenting your work and networking with your peers.

Stocking Shelves

My struggle in the community hospital setting is having the appropriate inventory for the patient population I need to serve. When I stocked the refrigerator during my golf club days the oldest inventory went up front and the new product went to the back. Later in graduate school I learned that was the FIFO method of inventory management. Blood Bankers have a unique twist thrown our way in that as blood sits on our shelves certain things happen that make an older unit less desirable than one collected a few days prior. The life span of a red cell is around 100-120 days depending on which literature you cite. Our job as blood bankers is to get the freshest blood to each patient we serve, so inventory management becomes more of an art than science.

Let’s take first the type specific debate. Some will say always transfuse type specific blood; if the patient is type A then the patient receives type A blood. Some will say to give whatever is most fresh; if we have fresh O cells an A person will get O. What I found when I first came to be the supervisor in my blood bank is that we were outdating a lot of type A blood. So instead of just decreasing the amount of type A, I also increased the number of type O I had on my shelf. This allowed me to be more flexible; I would give out more O when my inventory of A was low. Also, the blood I was giving out was always fresher than before I changed the inventory.

Let’s take this another direction. My policy states that any patient with an antibody has to have two red cell units set up so there is no delay if a transfusion is necessary. I would rather have two type O units typed for some antigens, because if the patient with the antibody doesn’t need it, the units are readily available to anyone else.  I use the flexibility of type O blood to be more versatile and to make sure that my patients are getting the freshest possible unit. I have searched for literature that says giving type specific blood is better for patient outcomes but I haven’t found it. If anyone has literature on the topic please send it my way.

This really comes down to what type of setting your blood bank serves. If you are in a medium size community hospital you will need to make these type of decisions to be flexible with your inventory. If you are a large medical center and are going through blood as soon as it gets delivered then you may not have to worry as much. The majority of us do not work for large centers, however, so we must look and analyze how we can best use this precious resource.

 

TommyTransfusion

Tommy Transfusion is the pseudonym of a blood bank supervisor in the midwest.

Blood Management: The Power of “Why”

There are five established questions that should always be embedded in our quest for knowledge and review within the ever-changing evidence base in medicine: what, who, when, how and why. Of these very important and inclusive queries, the final question wields the most power. For it is the why we do, or should do something that truly empowers us. “Why,” by definition, represents the cause, reason, or purpose for action.

Considering the rapid evolution of the evidence base in transfusion medicine and patient blood management, once again, these critical questions should be included in our appraisal. The why remains, however, the most important. Once we grasp that quality, safe, responsible transfusion practice is the purpose, then the what, who, when and how should more easily move forward.

The Joint Commission has begun evaluating patient blood management elements as part of a possible certification for hospitals. The AABB recently published a draft document of patient blood management standards for potential use by its participating facilities. The Society for the Advancement of Blood Management just announced a hospital affiliation program to align principles of blood management with the Society’s mission. All of these organizations are pushing the mission of evidence-based transfusion practice in order to promote patient safety and improve outcomes.

It is our duty as healthcare providers to constantly and consistently evaluate practices, whether they represent procedures, devices, pharmaceuticals; whether they are new or time-honored. Hemovigilance i.e. blood management, must also be included in this ongoing assessment.

Time and time again, the literature is pointing us in the direction of restrictive transfusion practices; avoiding unnecessary transfusion and utilizing blood products as part of our armamentarium when truly life-saving. This concept, thus exudes the ideals of appropriate patient care, best practices and stewardship of community resources. Our cause, our reason, our purpose is clearly to improve patient outcomes and well -being.

Embrace it! Get on board! It is the WHY!

Burns

-Carolyn D. Burns, MD, is the Medical Director of Transfusion Services at Strategic Healthcare Group and Assistant Clinical Professor in the Department of Pathology at the University of Louisville in Louisville, Kentucky. She also blogs for TheBloodyTruth.com.

30 Minutes or Less

How many people have heard of the 30 minute rule for units of returned blood? If you haven’t there is folklore that says once a unit of blood leaves the blood bank it is ok to return it to inventory if they get it back before 30 minutes are up. We even have a place on the documentation that accompanies the unit of blood to write down the time that we can accept a return. It was recommended to us that we get an infrared temperature meter so we could actually take the temperature of units when they are returned. One day I decided to play with my new toy and figure out how long a unit could really be out and still be ok to return. Our policy states a unit can be returned if the temperature is 10 degrees Celsius or colder.

I split my little experiment into two parts. Using an expired unit of blood, I left the unit on the counter and took the temperature every minute for 30 minutes. For the second part, I held an expired unit in my hand (simulating a nurse or transporter carrying the unit) and took the temperature every 2 minutes. In the first experiment the unit of blood reached 10°C in 19 minutes; at 30 minutes I recorded a temperature of 14°C. As expected, holding a unit in my hand sped up the rise in temperature; it took 12 minutes for the unit to reach 10°C. After 30 minutes the same unit was 17°C.  In both experiments I mixed the blood before rolling the unit of blood around the thermometer.

This very informal experiment confirmed my suspicion that the temperature of a unit of blood is environment dependent. Put the unit in a warm room and it will warm up faster than if it were in a cold room. When we dispense units we place the unit in a thin plastic bag; the plastic on the blood units themselves is thin as well. There is no insulation from the unit and our warm hands.

So what do you do with this information? If you have a policy or use the 30 minute rule, I recommend suspending it immediately. There is no way of knowing what happens to that blood once it leaves your blood bank. If you do not have an infrared temperature meter, put it on the capital wish list for 2014. They will save you from taking back blood that is not safe and it will put a finite cut off point for taking units back. Once we started using the meter we found that the majority of blood that comes back is not suitable for reissue and ends up being disposed. While we do waste blood, I feel much better knowing that the blood that we do take back is suitable for transfusion and is ultimately better for the patient.

It is performing little experiments like the one outlines above that keeps us all interested in the laboratory field. What other career can you have a question about something, know how to figure out an experiment to find the answer, and then carry it out to see if you were right or not?  Now the real question I have is: when I order the pizza for lab week what are the chances it gets here in 30 minutes or less?

TommyTransfusion

Tommy Transfusion is the pseudonym of a blood bank supervisor in the midwest.